Central JSM Dentistry

Review Article *Corresponding author

Jeff Burgess, Department of Oral Medicine, University

HIV and Dental Treatment of Washington School of Dental Medicine, USA, Email:

Submitted: 24 May 2016

Jeff Burgess* Accepted: 16 June 2016
Department of Oral Medicine, University of Washington School of Dental Medicine, USA
Published: 17 June 2016
ISSN: 2333-7133
Abstract Copyright
Approximately 1.1 million people are living with HIV, but 17 to 25 percent of these infected © 2016 Burgess
individuals are unaware of their disease status and as a result are not getting appropriate
medical treatment. Many of those who are untreated need dental care for caries, periodontal OPEN ACCESS
disease, and other oral pathologies. Although HIV positive individuals undergoing medical
treatment pose a significantly reduced risk for disease transmission, given the numbers of
untreated HIV infected, providers of dental care must continue to be vigilant with respect to their
preventative infection control measures. This article presents information on the epidemiology of
HIV-infected patients and practical clinical considerations that need to be utilized when treating
the AIDS patient.

OVERVIEW In the 2014 MMWR survey cited above assessing behavioral and
clinical characteristics of persons receiving medical care for HIV
According to the Morbidity and Mortality Weekly Report infection it was found that 22.8% of patients had unmet dental
(MMWR) [1] and other reports (http://www.cdc.gov/hiv/pdf/ care needs. And in another HIV Cost and Services Utilization Study
library/reports/surveillance/cdc-hiv-surveillance-report-us. (HCSUS) conducted by the RAND Corporation, an even much
pdf) there were over 1.1 million adults and adolescents infected higher 58 percent of the interviewed participants indicated that
with HIV in the United States and individuals newly infected per they did not receive regular dental care [6]. Research suggests
year ranged from 48,200 to 64,500 persons. Also reported is a that barriers to the pursuit of dental care in the HIV-infected
disproportionate burden of the disease within racial and ethnic patient include educational level (lack of a college education),
minorities, except for individuals who define themselves as not having dental insurance, ethnicity (being African American),
Asians. These statistics also indicate that gay and bisexual men of and “how HIV was contracted” (e.g. as a consequence of blood
all races are the ones most affected by HIV infection [2]. Although transfusion). Discrimination by dental health care providers is
the incidence of HIV infection does not appear to be increasing, another factor that has been identified as a barrier to appropriate
Dental personnel need to be aware that of the 1.1 million people care of the HIV patient [7].
living with HIV, approximately one individual in six is thought to
be unaware that they have the infection and as a result are not The above MMWR and other reports suggest that HIV patients
getting treatment. These individuals, if they need oral care, can being treated with antiretroviral therapy pose a limited risk to
potentially spread the disease in the dental setting [3]. dental personnel but a substantial number of individuals with HIV
remain untreated via HAART and thus pose a risk to dental staff
Even though the above statistics are distressing, additional and other patients. They also suggest that there is a significant
MMWR statistics from a recent 2014 study [4] are encouraging unmet dental need in the HIV-infected community with barriers
in that they reveal that of those patients knowing they are HIV to treatment both patient as well as practitioner dependant.
infected, most (88.7%) are taking prescribed antiretroviral
therapy (HAART) and as a result 71.6% demonstrate a virtually DENTAL INTERVENTION OF THE HIV PATIENT
undetectable viral load when tested (<200 copies/mL). Further, Several published references are available to guide dental
of those self-identifying themselves as sexually active, many have health care providers in the development of general office
also been assessed for other diseases such as syphilis, gonorrhea, procedures relating to the treatment of HIV-infected (and
and Chlamydia. Less encouraging, however, are the findings of other potentially infective) patients [8-11]. Dental personnel
another study assessing behaviors among injecting drug users involved in treating HIV-infected patients should be well aware
where 70% of men and 73% of women report having unprotected of the current literature and evidence based science that has
vaginal sex and lesser numbers (25% and 21% respectively) accumulated since 1983, when AIDS first came upon the scene.
unprotected anal sex. Further, many subjects in this latter study Some important highlights from the literature include the
had not been checked for Hepatitis C. These statistics underscore following:
the importance of effective infection control in the dental setting,
1. With the development of antiviral drug strategies, AIDS
particularly in practices located where there may be IV drug [5]
is now a chronic disease. Highly active antiretroviral
use.
therapy (HAART) has significantly reduced deaths and
Another statistic is of significance in relation to dental health. people with HIV can survive more than 20 years with the

Cite this article: Burgess J (2016) HIV and Dental Treatment. JSM Dent 4(2): 1062.
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disease. This means that more HIV-infected individuals provides regular updates of the current science and procedural
are likely to present for dental treatment over time [12]. regulations related to HIV (and other viral pathogens that can be
transmitted through dental care).
2. One in five (20%) of HIV-infected persons do not know
that they are infected [12]. Infection control
3. With the exception of a well publicized case of an HIV- Infection control includes identification of potential risk
infected Florida dentist who exposed patients to HIV based on patient history, protection of personnel via barrier
and several other isolated anecdotes [13] the number of techniques, instrument and treatment room sterilization,
reports documenting practitioner to patient spread of HIV and decontamination of laboratory materials (e.g. models,
come from care delivered outside the USA. It is reported impressions, etc.). In general, every patient should be considered
that thousands of patient records reviewed for 75 HIV- as a possible transmitter of disease and treated the same in terms
infected dentists and physicians have not identified a of infection control procedures.
single problem with HIV transmission of practitioner to
patient [14] in the USA. Patient history related to risk

4. Exposure to blood borne pathogens is significantly There are certain factors within the medical history that
reduced via the use of personal protective equipment can indicate greater risk of HIV or other contagious infection.
(PPE) during dental treatment but the use of PPE does not Unfortunately, in the dental setting, some of the questions
prevent all possible exposures (i.e. needle sticks); hence necessary to get at information related to risk of infection with
proper needle technique and disposal remains extremely HIV are difficult for clinicians and staff to pose to patients.
important. Nonetheless, while these important pertinent questions may
not be asked of patients, they should be appreciated. Historical
5. Cross contamination from one HIV patient to another factors which are associated with increased HIV (and some other
can occur via contaminated instruments or equipment infectious diseases such as Hepatitis C) risk include: men having
surfaces. sex with men, more than one sex partner – particularly if one
6. Systematic literature review indicates that at this time it of them injects drugs, use of and sharing of needles, syringes,
cannot be said with reasonable certainty that HIV patients cookers or other equipment used to inject drugs, and recent
are at a greater risk for the development of treatment infection with another sexually transmitted disease.
complications following invasive dental treatments such Other less personally invasive questions that can be more
as orthognathic surgery, periodontal therapy, dental easily asked of a patient in the dental setting to access for possible
implants, prophylaxis, scaling, or endodontic therapy (in HIV (via verbal history or questionnaire) include the presence of
comparison with non-HIV patients) [15]. symptoms indicating illness such as fever, weight loss, shortness
7. The Americans with Disabilities Act (ADA), enacted in of breath or diarrhea, the occurrence of frequent fungal or yeast
1990, designated HIV-infected people, even if they are infections, liver infection (e.g. hepatitis), frequent recurrent cold
asymptomatic, as handicapped , and as such patients with sores or oral herpes or other sexually transmitted diseases, prior
HIV are protected by law against discrimination, including blood transfusion, and whether the patient is caring for an HIV
that which might occur in a dental office, for example, by patient who has hemophilia [17].
refusal of treatment. Unfortunately a lack of education Laboratory and screening tests
regarding the disease has been found to lead five percent
of dentists in one US city surveyed to refuse treatment to If HIV infection is suspected it is best to refer the patient for
HIV patients, in violation of law [16]. The risk of suit may medical evaluation and laboratory assessment where appropriate
be greater than the risk of disease transmission. screening tests can occur. The standard recommended CDC
screening test for HIV infection is the EIA or enzyme immunoassay
CLINICAL CONSIDERATIONS IN TREATING THE which evaluates the presence of HIV antibodies. This test is
HIV-INFECTED PATIENT performed on a blood draw which is a procedure not typically
provided in the dental setting. Two tests are required to confirm
Risk management
a positive diagnosis. Other tests include the evaluation of oral
Risk management includes the development and fluid (not saliva) collected by a special collection device and
implementation of office procedures for identification of possible evaluation of urine with the latter less sensitive and less specific
HIV-infected individuals, protective measures to prevent cross than the saliva test. In addition to the above, a home collection
infection of HIV from patient to staff, staff to patient, and patient test kit has been developed for patients suspecting HIV [18].
to patient, reporting of exposures should they occur, and referral
for additional medical care and counseling of a suspected HIV- Barrier techniques
infected patient in accordance with the most current United States In 1993, to facilitate infection control and reduce risk
Public Health Services (USPHS) recommendations. Every dental of transmission of infection (generally and not necessarily
office should have available to staff a comprehensive written related to HIV), the CDC published specific infection control
program for preventing and managing occupational exposures criteria for treating dental patients [19]. These recommended
to blood and other potentially infectious agents and a designated procedures and subsequent modifications (in 2003) [20] are
compliance officer (typically an assistant or hygienist) that now incorporated into many State dental practice acts and have

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become the standard of care in the management of all patients operative tray or prior to disposal). Syringes and needles,
and not just those with infectious disease. The cited document scalpel blades, and other sharp items must be placed in
(above) can be used to develop a manual on infection control puncture-resistant containers for later disposal (there
for office use. A PDF e-book has also been released outlining are several companies that provide containers and pick
current recommendations [21]. Some of the many recommended up services). Needles should not be bent or broken prior
procedures include the following. to disposal.
For protective attire and barrier techniques For sterilization or disinfection of dental instruments
1. Latex or vinyl gloves must be used when there is 1. EPA-registered hospital disinfectant with tuberculocidal
potential for contacting blood, blood-contaminated saliva, activity (intermediate-level disinfectant) is recommended.
or mucous membranes (although not stated - gloves
2. It is important to pay attention to the category of items
should be worn for all procedures and for all patients).
Non-sterile gloves can be used for examinations and other needing disinfection: those in the critical category are
nonsurgical procedures; sterile gloves should be used for ones that penetrate soft tissue, contact bone, enter into
surgical procedures. or contact blood; semicritical items contact mucous
membranes or non-intact skin but do not contact bone or
2. Hand washing needs to occur before placement of gloves blood; and noncritical items are ones that contact intact
and before placement of new gloves between patients. skin. The latter includes, for example, the radiograph
Old gloves need to be discarded. Washing or attempts at head/cone, blood pressure cuff, face bow or other
disinfection or sterilization of previously worn gloves is hardware used in restorative care, and the pulse oximeter.
not approved as these efforts are ineffective, will destroy
the integrity of the gloves, and can easily cause cross- 3. Each dental office should have a designated central
contamination. processing area divided into sections for receiving,
cleaning and decontamination, preparation and
3. Chin-length plastic face shields or surgical masks and
packaging, sterilization, and storage.
protective eyewear need to be worn to protect the eyes
from splatter during dental treatment. Masks need to 4. Heat-tolerant dental instruments must be sterilized by
be replaced between patients and during patient care if autoclaving, dry heat, or unsaturated chemical vapor. For
they become wet or moist. Face shields/eyewear should heat-sensitive critical and semi-critical instruments and
be washed with an appropriate cleaning agent and devices, liquid chemical germicides registered by the FDA
disinfected between patients. as sterilants can be used. Liquid chemical sterilants are
highly toxic and must be handled carefully.
4. Protective reusable or disposable gowns, laboratory coats,
or uniforms must be worn when treating patients. These 5. The dental office should establish and use some type of
items should be removed prior to exiting the treatment monitoring system (a simple pad or software program) to
area and before initiation of laboratory or other non- make sure that the sterilization equipment is effective.
treatment patient-care activities. It is recommended that
reusable protective clothing be washed using a normal 6. Manufacturer’s instructions need to be followed for
laundry cycle and changed daily if visibly dirty. the cleaning and sterilization of hand pieces; and after
operative use the dental hand piece should be run for a
5. Impervious-baked paper, aluminum foil, or plastic covers minimum of 20-30 seconds to clear the water lines.
should be placed on light handles or x-ray unit heads
and other equipment where cleaning and disinfection 7. Appropriate barriers should be used on dental
is problematic. These materials should be removed, components that are permanently attached to dental
discarded, and replaced between patients (after the units such as saliva ejectors, high-speed evacuators, and
removal of contaminated gloves and hand washing). the air/water syringe followed by disinfection with an
EPA-registered disinfectant (intermediate-level).
6. Rubber dams, high-velocity air evacuation, and proper
patient positioning is recommended to reduce the Dental unit water quality
formation of salivary particles and aerosols during
1. Each dental office should develop a strategy for the
treatment.
cleaning and disinfection of blood spills, medical waste
7. Splash shields need to be used in the dental laboratory. disposal, and utilization of state-approved treatment
technologies for containing blood and saliva discharge
For sharp instrument and needle management into the sewer system.
1. Potentially infective needles, scalpel blades, wires, and
2. To reduce the possibility of virus and other
other sharp instruments must be handled very carefully.
microorganisms contaminating treatment water within
2. A one-handed ‘scoop’ technique or a mechanical device dental hand pieces, ultrasonic scales, or air/water
designed for holding the needle sheath curing recapping syringes, these items should be discharged for 20-30
is the recommended approach for recapping (all needles seconds after each patient’s visit and before next use
need to be recapped after use or when replacing on the (even if a device is equipped with an antiretraction valve).

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3. It is important to consider water quality monitoring. Syringe (Dentsply MPL Technologies, Susqueanna, PA, USA), the
SafetyWand (Milestone Scientific Inc, Livingston, NJ, USA) which
4. Sterile solution systems should be used to cool and irrigate
is touted as the first injection device to be fully compliant with
during oral surgical procedures (including implants).
OSA regulations under the federal Needlestick Safety Act, and the
Other delivery devices that can be considered to deliver
RevVac safety syringe. Few of these devices have been subjected
sterile solution include bulb syringes or other single-use
to stringent study related to purported prevention efficacy but
disposable products.
they might be considered if there is concern regarding needle
Infection control related to laboratory supplies and stick injury.
materials and biopsy specimens
Sharps injury and HIV exposure
1. It is important to disinfect materials that will be sent to a
Sharps injuries and other forms of exposure can occur during
laboratory. These include impression materials, models,
dental treatment and if the patient is known to be HIV-infected,
appliances, and other materials that have been potentially
appropriate post exposure management is critical. The CDC has
contaminated by blood or saliva. Disinfection begins with
published information on their web site [24]: http://www.cdc.
thorough removal of blood and saliva.
gov/niosh/topics/bbp/emergnedl.html.
2. An EPA-registered hospital germicide labeled with anti-
It is suggested that post needle stick the affected area should
myobacteria (tuberculocidal) activity (defined as an
be immediately washed with soap and water; splashes to the
intermediate-level disinfectant) is recommended for use
nose, mouth (with contact with mucosa), or skin should be
on laboratory supplies and materials.
flushed with water; the eyes should be irrigated with clean water,
3. Materials returned from the dental laboratory need to be saline, or sterile irrigating solutions post exposure by fluids. Any
cleaned and disinfected prior to placement in the patient’s exposure incident should be immediately reported and medical
mouth. treatment should be quickly pursued (within one to two hours).
Even given exposure by percutaneous needle stick, the risk of
4. The dental office must communicate with the dental
contracting AIDS is small (estimated from a number of studies to
laboratory instructions regarding handling of
be in the range of 0.32%) [25,26]. Mixed risk results are reported
contaminated materials [11].
for mucous membrane exposure with one source indicating an
5. Biopsy specimens need to be handled with care. When estimated risk of .09% [27] and another less that .03% [28].
placing a specimen for transfer to pathology it is important
Reported factors that increase the risk of HIV infection
to make sure that the outer surface area of the container
following exposure include: deep penetrating injury, visible blood
is not contaminated. If contamination is suspected, the
on the injury device, injury from a needle placed in a patient’s
container needs to be disinfected prior to mailing or
artery or vein, and inoculation by a terminal HIV-related patient
transfer.
not on therapy or with a very high viral load [29].
The 2003 guidelines also provide additional sterilization
It is important to note that the risk of infection by needle
information on a variety of topics such as the handling of
exposure from an untreated HIV-infected patient is low to begin
extracted teeth, laser/electrosurgery plumes or surgical smoke, with [30] and if the patient is on HAART and has minimal HIV
and dental radiology. Additional infection-control internet virus at the time of the needle stick injury it may be essentially
resources are also provided in the document. The Organization nonexistent. Further, it should be appreciated that pure saliva
for Safety and Asepsis Procedures (osap.org) has also published a not contaminated by blood has not been implicated in the
good reference source describing CDC guidelines [22]. transmission of HIV [31]. The virus, however, has been isolated
OTHER CLINICAL CONSIDERATIONS from subgingival biofilm [32] in HIV-infected patients. Hence, to
be on the safe side the above precautions should be used in case
Needle placement of any type of exposure involving contact with oral fluids.
If needles are to be used repeatedly they should be recapped
Managing dental Apprehension in the HIV patient
and placed in a sterile area on the instrument tray. Techniques
for recapping have been previously described. Fear of dental procedures including injections and subsequent
numbness is common in both healthy [33] and HIV infected
Syringe systems designed to reduce needle stick
patients. But HIV infected patients experience other fears related
injury to dental care not typically encountered by healthy patients. In
To reduce needle stick exposure associated with a qualitative study assessing HIV-related stigma in the dental
conventional syringes several manufacturers have marketed setting [34], 45 percent of 60 HIV-infected individuals interviewed
devices designed to automatically cap the needle post-use. Many indicated that they anticipated judgment, stigmatization, or
of these ‘safety’ dental syringes have been removed from the disrespectful treatment in the dental office because of their HIV
market because of user dissatisfaction (and at least one study status. Thirty-five percent endorsed a fear of the dentist and
suggesting they may be no safer than traditional needles [23]) an equal number concerns about confidentiality and receiving
but several are still available. They include the Ultra safety humane treatment. Some were concerned with giving HIV to the
Plus XL Syringe (Septodont, Lancaster, PA, USA), the Ultrasafe dentist. The authors of this study conclude that dental “providers
Syringe (Safety Syringes Inc, Carlsbad, CA, USA), the HypoSafety should be aware of and better manage these issues”.

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Management of dental fear may require counseling, sedation, 9. John G. Bartlett, Cheever LW, Johnson MP, Paauw DS. Health Resources
and sometimes cognitive behavioral psychology. Several and Services Administration. A Guide to Primary Care for People with
strategies related to local anesthesia and oral sedation may be HIV/AIDS. HRSA; 2004: 1-167.
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vibration injection syringes, the use of lidocaine and prilocaine Adult HIV/AIDS Treatment. HRSA; 2006: 1-57.
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scaling and root planning, and the use of the sedative/anxiolytics Dental Team. Year Book Medical Publishers, Inc. Chicago, 1986.
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12. Centers for Disease Control and Prevention. Fact sheets on HIV/AIDS.
recommended if repeated injections are anticipated but recent
research suggests that there are toxicity issues (paresthesia) 13. Possible Transmission of Human Immunodeficiency Virus to a Patient
associated with this anesthetic [36] so it should be used with during an Invasive Dental Procedure. MMWR Surveill Summ. 1990;
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SUMMARY Practice. 2007.
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providers. The primary concerns identified in one study relate to J Am Dent Assoc. 2002; 133: 195-203.
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16. Sears B, Cooper C, Younai FS, Donohoe T. HIV Discrimination in Dental
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that dental personnel will wear masks, gloves, and glasses [37], The Williams Institute. 2011.
but as indicated in this written article, CDC and ADA guidelines
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extend far beyond these simple measures; and it is recommended
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infection control guidelines. This article discusses important
21. Centers for Disease Control and Prevention. Guidelines &
clinical considerations helpful in managing the dental needs of
Recommendations. 2014.
HIV-infected patients.
22. New CDC Infection Control Guidelines for Dentistry. 2004.
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Cite this article

Burgess J (2016) HIV and Dental Treatment. JSM Dent 4(2): 1062.

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